Peripheral Intravenous Cannula, Adults and Children (Not Neonates)

/ CHHS15/116

Canberra Hospital and Health Services

Procedure

Peripheral Intravenous Cannula, Adults and Children (Not neonates)

Contents

Contents

Purpose

Alerts

Scope

Section 1 – Site selection and insertion of PIVC

Section 2 – PIVC post insertion care and management

Section 3 – PIVC Administration Sets (changing and frequency)

Section 4 – PIVC removal

Implementation

Related Policies, Procedures, Guidelines and Legislation

References

Definition of Terms

Search Terms

Purpose

The purpose of this Clinical Procedure is to outline the safe and effective insertion, management, (including line changes) and removal of a Peripheral Intravenous Cannula (PIVC) in people being cared for under the direction of Canberra Hospital and Health Services (CHHS).

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Scope

Alerts

Under no circumstances, are nurses of any experience, in any division, permitted to insert external jugular access cannulas.

PIVC insertion is a Standard Aseptic Technique procedure. Standard Aseptic non touch technique can be performed by experienced staff without touching key areas (i.e. insertion site). If staff do not feel confident to complete the procedure without touching these areas, then sterile gloves must be used.Please refer to CHHS Standard Operating Procedure (SOP), Aseptic Non Touch Technique CHHS14/011.

If a PIVC is contaminated at any stage during insertion discard it and use a new PIVC.

Where the PIVC has been inserted in an emergency situation where aseptic technique cannot be assured, the cannula must be replaced within 24 hours, in order to prevent infection.

All other PIVC must be replaced WITHIN 72 hours, or earlier when there are local or systemic signs of inflammation/infection.

Exceptions

• Paediatrics – the line remains in until no longer required, unless there are signs of inflammation/infection.
• Life threatening situations where a PIVC older than 72 hours is insitu and functional and alternative appropriate access has not yet been inserted. The reason for retaining a PIVC beyond 72 hours must be clearly documented in the patient’s medical records.

For patients requiring a PIVC for ongoing treatment or management e.g. IV Antibiotics, fluid resuscitation, DO NOT REMOVE the existing PIVC until a new one is successfully sited.

In the situation where IV access is difficult, a decision regarding alternative IV access should be made, taking into account urgency and requirementof access. This may include:

• Switching to oral therapy.
• A more experienced clinician attempting further PIVC insertions.
• Team consideration of an alternative IV access, e.g. peripherally inserted central line, central venous line.

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Scope

This guideline applies to the following professionals at CHHS:

• Medical officers
• Registered Nurses/Midwifes working within their scope of practice
• Enrolled Nurses working within their scope of practice
• Students under direct supervision
• Radiographers who have completed:

• Administration of Iodinated Contrast Media (eLearning-2017)
• Aseptic Technique (el-2016-V4)
• Competency Assessment: Flushing of PIVC’s and administration of contrast media.

PIVC insertion may only be performed by staff that have completed appropriate IV cannulation training and credentialing.

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Section 1 – Site selection and insertion of PIVC

Equipment

• Dressing trolley
• IV starter pack plus alcohol-chlorhexidine 2% swabs orbasic dressing pack plusAlcoholchlorhexidine 2% swabs and occlusive transparent film dressing. For patients with a history of chlorhexidine sensitivity/allergy, use:
• 5% alcohol-based povidone-iodine swab
• ≥70% alcohol
• 10% aqueous povidone-iodine (suitable for patients in whom alcohol is contraindicated)
• Infusion device (safety cannula)
• Needle less connection valve, safesite or caresite or Extension set with Needleless connection valve or safevalve
• Syringe 5ml
• Drawing up needle
• Sodium chloride 0.9% ampoule or Pre filled Sodium chloride 0.9% (0.9% NaCl)
• IV giving set (if required)
• Infusion pump or Syringe driver (if required)
• Tourniquet
• Tape for securement of giving set
• Clean gloves or sterile gloves (decision dependent on skill level)
• Safety goggles or protective face shield
• Underpad
• Local anaesthetic if required (note this is not mandatory)
• Syringe 2ml with 25g needle if giving local anaesthetic
• Alcohol based hand rub (ABHR).

Procedure

1)Staff must consult the Medical Officer responsible for the patient’s care before insertion to ensure that a PIVC is required, alternatives should be considered and the benefits of PIVC insertionshould outweigh the risks.

2)When repeated or prolonged administration of chemical irritants, such as potassiumchloride or vancomycin is required, central venous access should be considered, to avoid peripheral vein damage.

3)When selecting a PIVC, ensure that it is equipped with safety engineered devicewith sharps injury protection.

4)The size of the PIVC should be determined by the intended use (e.g. blood and blood products, drug therapy, hydration etc), the condition of the patient’s veins, likely length of time PIVC is expected to remain in situ and the insertion site.

5)The PIVC should be the shortest and smallest gauge that can meet the anticipated clinical need (i.e. operating theatre, trauma, labour) to ensure optimal flow.

6)The staff member should wash their hands or apply ABHR.

7)Explain the procedure to the patient and obtain informed verbal consent, if appropriate, as perCHHS SOP, Consent and Treatment, DGD12-044.

8)Conduct positive patient identification procedure as per CHHS Clinical Procedure, Patient Identification and Procedure Matching, CHHS14/052.

9)Check the patient’s history for bleeding disorders, medications (e.g. warfarin, aspirin) and allergies, including whether the patient has allergies to skin antiseptics (e.g. chlorhexidine or iodine) or dressing materials.

10)Check for previous difficulties with cannulation and/or IV therapy.

11)Ensure privacy.

12)Wash hands or apply ABHR.

13)Set up, prepare, assemble and open equipment.

14)Don protective eyewear.

15)Position patient comfortably, supporting proposed area of insertion. Place the underpad as required.

16)Apply tourniquet, select vein then release tourniquet.

17)Select the most appropriate vein for insertion of the PIVC. Points to consider include:

• Patient’s activity level
• Size and condition of patient’s veins
• Indication for PIVC and expected duration of PIVC
• Position of patient during any planned procedure(s)
• Use non-dominant forearm if practical
• Use basilic or cephalic veins on the posterior (dorsal) forearm if possible
• The metacarpal veins on the dorsum of the hand are easier to visualise but are more liable to clot, difficult to stabilise, and prone to vessel damage
• In patients with chronic renal failure, the use of the anterior (ventral) forearm veins (especially the cephalic vein) should be avoided, as these may berequired for fistula formation for dialysis.

Avoid the use of veins in the following sites:

• Areas of flexion, e.g. antecubital fossa, or bony prominences
• Vein easily damaged
• Uncomfortable
• Areas below previous cannulation site
• Vein may be damaged
• Bruised or phlebitic areas
• Poor venous return
• Pieces of clot can be dislodged into the system
• A limb with an arteriovenous fistulae or shunt
• May compromise haemodialysis access
• An arm on the same side as a previous lymph node dissection, mastectomy or affected by cerebrovascular accident
• Poor venous and/or lymphatic return
• An infected limb e.g. with cellulitis
• A limb with a peripherally inserted central catheter (PICC) or implanted venous access device (port-a-cath)
• Lower limbs (with the exception of infants)
• Risk of deep vein thrombosis
• Limits access, patient comfort and mobility.

18)Prepare venepuncture site as required e.g. remove hair at the insertion site (prior to antiseptic application) if necessary, using clippers to improve adherence of the dressing.Clean the skin with neutral soap and water if the insertion site is visibly dirty.

19)Wash hands or apply ABHR.

20)Don gloves, sterile or non sterile according to skill level.

21)Place sterile towel under the selected area.

22)Clean insertion site and surrounding area using a single-use alcohol-based chlorhexidine gluconate swabs (>0.5% chlorhexidine in >70% isopropyl alcohol) swab or other appropriate cleanser if the patient has a chlorhexidine allergy (see equipment list). Apply antiseptic to coveran area of approximately 5 x 5cm in a circular motion with lightfriction, and allow the skin to air-dry (do not wipe, fan or blotdry the area). Allow at least 30 seconds to dry.

23)Reapply tourniquet, using sterile gauze or with use of an assistant.

24)If required, inject local anaesthetic intra dermally, beside the elected IV site creating a small bleb on the skin. Do not puncture vein when anaesthetising the skin. Draw back on syringe to identify placement ensuring you are not giving intravenous lignocaine.

25)Insert cannula ensuring vein is punctured (visualising ‘flashback’ at the hub of the cannula).

26)Advance plastic cannula and withdraw the stylet.If the PIVC fails to enter vein, do not attempt to reintroduce the stylet into the insituPIVC. Remove entire device and commence again with a new PIVC and a new IV starter kit if sterility of the kit has been breached.

27)Release tourniquet, attach needleless injection cap or extension set with needleless injection cap to the hub of the cannula and flush cannula with 0.9% NaClto confirm placement.

28)Secure the IV cannula with Steristrip, over the hub of the cannula and occlusive transparent dressing.

29)Clearly record the date and time of insertion of the PIVC on the tape or occlusive transparent dressing.

30)Insertion site should remain visible at all times.

31)As soon as possible after the insertion of the PIVC, document the date, time, site and size of the cannula in the patient’s clinical records and nursing care plan.

32)A maximum of two attempts at PIVC insertion is permitted; following two failed attempts, consult a more experienced clinician. If a more experienced clinician has made two attempts, the clinician is to decide whether they continue attempting to insert the PIVC, or whether an alternate IV access should be considered.

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Section 2 – PIVC post insertion care and management

Equipment

• Sterile basic dressing pack
• Alcoholic chlorhexidine 2% swabs
• Occlusive transparent dressing
• Steristrips
• Splint and bandage or elasticised net, if required
• Underpad
• Disposable gloves
• Sterile gloves
• Protective goggles or protective face shield
• ABHR
• 1 x 10ml ampoules 0.9% NaCl for injection
• Kidney dish
• Syringe 10ml x 1 and drawing up needle or Pre filled 0.9% NaCl syringes
• 70% alcohol swabs.

Procedure

Observation

1)The PIVC insertion site must be observed and documented in the nursing care plan and clinical notes each shift and/or whenever the PIVC is accessed for IV medication. The site should be checked to ensure the PIVC site is phlebitis or infection free, therapy has not infiltrated the tissues, the site is clean, dry and the dressing is intact.

2)Explain the procedure to the patient and ensure privacy.

3)Wash hands or apply ABHR.

4)Observe the dressing ensuring that the dressing is dry and intact.

5)Palpate the insertion site for tenderness; ask the patient if it is painful.

6)Check that the date of insertion of the PIVC is legible on the dressing and when the PIVC requires changing.

7)Observe for any signs of infiltration, extravasion, inflammation, swelling and redness before and after access and/or each shift.

8)If there are any signs of adverse reactions, e.g. phlebitis, infiltration, pain, tenderness, the PIVC needs to be removed and reported to the medical officer. The initiation of the removal of the PIVC is by a registered nurse or medical officer only.

9)Document in the patient’s clinical record the observations of the PIVC site every shift.

10)Medical staff are to review the requirement for the PIVC at least daily and document in the clinical record the indication for the ongoing use of the PIVC (e.g. continue IV fluids or IV antibiotics) or requirement to have the PIVC removed.

11)Redress the PIVC site if required.

Redressing the site

1)The PIVC site should be redressed if the dressing becomes soiled, damp or loose.

2)If the site needs to be redressed, explain the procedure to the patient and ensure privacy.

3)Wash hands or apply ABHR.

4)Don gloves and protective goggles.

5)Prepare equipment.

6)Wash hands or apply ABHR.

7)Position the patient comfortably. Support the proposed site.

8)Remove and discard the soiled dressing.

9)Observe the PIVC site for signs of inflammation, infection or infiltration. Document redressing of cannula, with date and time in patients clinical notes and nursing care plan

10)Remove the PIVC if these conditions are apparent, report to the medical officer and follow Section 3; step 12 of this procedure.

11)Wash hands or apply ABHR.

12)Secure the IV cannula with Steristrip, over the hub of the cannula and occlusive transparent dressing.

13)Clearly record the date and time of insertion of the PIVC on the tape or occlusive transparent dressing and document the date, time, site and size of the cannula in the patient’s clinical records and nursing care plan.

14)The insertion site should remain visible at all times.

Flushing of a PIVC

1)Flushing of PIVC in situ maintains PIVC patency, minimises adverse reactions and prevents thrombus formation.

2)Flushing of a PIVC must be performed for the following:

• Pre and post administration of routine intravenous therapy including chemotherapy
• Pre and post medication administration
• Pre and post routine blood administration and/or blood sampling
• Prescribed order from a medical officer
• 6th hourly to keep the vein patent.

3)When preparing for flushing of a PIVC, collect equipment and place in clean kidney dish.

4)Don protective goggles.

5)Wash hands or apply ABHR.

6)Don gloves.

7)Draw 0.9% NaCl solution into 10ml syringe using drawing up needle (label as per National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines as applicable) or use pre filled 0.9% NaCl syringe.

8)Swab needleless injection valves vigorously for 10 seconds with an 70% alcohol swab and allow to dry (30-60seconds).

9)Check PIVC site for signs of infiltration and /or phlebitis or infection. If present remove the PIVC and arrange for insertion of a new PIVC (refer to section 1).

10)Slowly inject the 0.9% NaCl to flush the PIVC.

11)If the patient experiences pain or tenderness, remove and resite PIVC as per Section 1.

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Section 3 – PIVC Administration Sets (changing and frequency)

This Section describes the process and frequency for changing administration sets on Peripheral intravenous cannula (PIVC). IV administration sets include both the IV line and any additional attachments such as 3-way luer locks, Y connections and extension tubing that may be added.

Line Use / Frequency of line changes
Standard fluids used continuously and not disconnected / Every 72 hours
Used to infuse blood and blood products / When transfusion is complete or every 12 hours
Lipid containing substances (including TPN) / Every 24 hours
Neutropenic patients / Every 24 hours (daily)
Main lines with additives / Every 24 hours
Side lines and syringe lines for intermittent medications, e.g. antibiotics / Single use
Propofol / Every 12 hours or when the vial is changed

NOTE:

• Changing of an Intravenous Line is a STANDARD Aseptic Non Touch Technique procedure.
• When resiting a PIVC the administration set and all additional attachments, fluids etc. must be changed at the same time.
• IV tubing sets should not be disconnected for routine care, when unavoidable and tubing sets have been disconnected, replace the entire IV tubing.
• Best practice states that once disconnected IV tubing should not be reconnected. However a health care professional can risk assess the situation in case of urgent therapy.

Equipment

• IV administration set(s)
• IV fluids as ordered
• 70% alcohol or 70% alcohol and 2% chlorhexidine
• extra gauze as necessary
• clean gloves

Procedure

1.Confirm patient identity, select prescribed fluid and second check with authorised personal.

2.Explain the procedure to the patient, gaining verbal consent if appropriate and ensure patient privacy.

3.Wash hands or apply Alcohol Based Hand Rub (ABHR).

4.Using aseptic non- touch technique assemble equipment, prime lines including all associated connections with IV fluids, ensuring no air is present within the administration set and close clamp. Hang newly primed administration set and fluid on an infusion stand.

5.Wash hands or apply ABHR.

6.Don clean gloves- STANDARD Aseptic Non Touch Technique (ANTT).

7.Clean needleless injection cap vigorously with Chlorhexidine 2% alcohol 70% swab for 10 seconds, allow to drying for 30 seconds.

8.Using ANTT, attach IV giving set to needleless injection cap.

9.Open the clamp to the patient; ensure flow and set rate of infusion.

10.Discard equipment and remove gloves.

11.Wash hands or apply ABHR.

12.Ensure that all lines are labelled with the date of commencement of infusion and the type of infusion and document in clinical notes.

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Section 4 – PIVC removal

Equipment

• Gauze swab or occlusive transparent dressing orInjection site pressure pad
• Safety goggles
• Gloves
• Underpad
• Specimen container, if required
• Sterile scissors if required if cutting tip off after removal of the PIVC
• ABHR.

Procedure

1)PIVC are to be removed and/or replaced:

• as soon as they are no longer clinically required OR
• when there are signs of adverse reactions or inflammation/infection/infiltration OR
• within 24 hours for PIVC inserted in emergency situations or by ambulance officers OR
• within 72 hours (with the exception of paediatric patients or adults with life threatening situations where alternate IV access is not available).

2)If ongoing IV access is required, a replacement PIVC should be in situ prior to removal of the existing PIVC.

3)If a patient is admitted with a cannula inserted by paramedics/ambulance officers or from another institution and it is not labelled, or the date of insertion is not documented, the cannula must either be removed or:

• Dated, if the insertion date is known.
• Have the words ‘ambulance’ or other similar/appropriate written on the dressing to clearly identify it including current date and time

4)When removing PIVCs, explain the procedure to the patient and ensure privacy.